How To De-Escalate Angry Patients in Telepsychiatry (Before It Spirals)

Patient Encounters That Stay With You

There are some patient encounters that are just burned in our brains, and this can happen in our training and also in our career, where the encounter was just so significant and usually there was emotion involved, sometimes positive emotion, where you helped somebody make a decision that would change their life. But maybe it was for negative reasons. Maybe it was because the patient got angry and tore you a new one, if you know what I mean.

 

And that happens. So if you’re telling me that that’s never happened to you, where a patient was never angry with you, I’m pretty sure that you’re lying because everybody who’s had any kind of experience in this space knows that patients can get angry. For example, when I was working at the jail, I had a patient who wanted Wellbutrin, which as many of us know can be abused in a correctional environment.

 

And so it’s often something that doctors have to say no to when a patient asks for it. In this case, the patient wanted Wellbutrin and was not going to leave after I prescribed him Wellbutrin. I tried to reason with him, but he continued to escalate until he started yelling at me, at which point the custody officer had to end the meeting.

 

But for a moment I felt threatened. I felt physically threatened by this patient who was really angry, and I had failed to understand that I was not going to de-escalate him using logic. I was not going to convince him that he did not need Wellbutrin. Another example happened when I was in my internship, where I was trying to convince the wife of a patient in intensive care that really there was no more reason to continue life support because the patient had lost basically all function and there was just needless suffering.

 

There was no chance the patient was going to get better, and I tried to have a conversation with the patient’s wife, and she again just tore me a new one. I mean, she was so angry with me, and those encounters and others I will never forget because it either triggered fear or shame, or I was just shocked by the patient’s response or the session didn’t end well.

 

Why De-Escalation Skills Matter

Luckily, these kinds of encounters don’t happen every single day, but they certainly happen enough where knowing how to recognize somebody escalating and then de-escalating that patient is a very important skill. In fact, I would say it’s near the top of skills that we need to have as mental health professionals. Why do we need to have the skill? Well, when a patient is angry, they can stop listening to you.

 

They’ll interrupt you. They’ll argue with you, refuse to answer questions, they’ll withhold important information from you, and they’ll refuse treatment or refuse medications that you want to give them. They will refuse other kinds of treatment, and they’ll probably leave the appointment and disconnect from the video visit or just walk out of the room if you’re seeing them in person.

 

In some cases, the escalation could lead to yelling, threatening, aggression, or some sort of emergency. And so this is a really important thing to understand, that patients sometimes need to be de-escalated. And this is especially important in video where you’re not there with the patient. And really your words and your appearance are the only thing, oftentimes, that will de-escalate the patient.

 

You might not have somebody on the other end of the camera. So it’s really important that we understand how to de-escalate.

 

Root Causes of Patient Anger

But first, let’s figure out why a patient is angry. Certainly if you’re like me, you’re a great psychiatrist, so they shouldn’t be angry with you, right? Well, too bad, they’re going to be angry anyway. Even if you’re a great psychiatrist, they’re going to be angry in certain situations.

 

Maybe they’ll be intoxicated on drugs or alcohol. This is a shocker, but when people are drunk or high, they sometimes can get angry easily. Yes, I know that’s surprising to hear, but obviously that is true, even when they’re in withdrawal. If you know, I’ve never been in drug withdrawal, okay, but I imagine that I would not be very pleasant to deal with if I was. I would be feeling sick, I would be feeling unstable. So even in withdrawal, you can have people be angry with you. Mania. Have you ever had a patient who is manic and angry? Yes, we all have. And so that is a major reason. People can become psychotic and angry. In fact, another patient that I remember, my gosh, he was so angry.

 

He was so paranoid with me that I couldn’t even talk to this patient. So being psychotic does not always end well with the patient liking you and everything Kumbaya. I mean, the patient will often be paranoid and hate you and be afraid of you. Let’s not forget that fear and anger go together, so if somebody is afraid, then they might be angry.

 

And therefore, if somebody is angry, you have to think: are they afraid of something? Is that the thing? They can have anxiety. They can have a trauma response, trauma-related anger. Maybe they’re confused and delirious. So there are all kinds of clinical reasons why a patient could be angry. Situational factors are also a big category of why a patient might be angry.

 

How many patients want to talk to you? Okay, I’m guessing that there are some that don’t want to be there, that don’t want to talk to you, and they’re being involuntarily treated or being evaluated involuntarily. Maybe they’re angry because they know that they’re going to be placed on a hold. Maybe they feel that they’ve been mistreated. They just want to go home.

 

They’ve been waiting too long in the emergency department. They’re frustrated with the questions that we ask. You know, so often we’re going to have to ask questions that they’ve been asked already several times. And so how many of you have had that reaction where it’s like, “Yeah, I don’t want to talk to you, doctor. I’ve already answered these questions. Why do I have to answer these questions again and again?” 

 

Maybe they’re getting bad news, and maybe they’ve gotten bad news and they’re just angry at the world. Maybe they feel that nobody’s listening to them. So these are all reasons why a patient might be angry—the situational reasons. And anger itself is not necessarily a problem if it’s contained and if it goes away, but sometimes it escalates.

 

The Benefits of De-Escalation

And so it’s so important that we de-escalate a patient or at least recognize the signs that they’re getting angry on video. So what are the benefits of having a skill set like this where you can de-escalate patients? Well, that means that you will prevent a difficult interaction from becoming a crisis. And let me tell you, you know, I always say you want to be likable as a doctor, right?

 

And you want your patients to like you, and you want the staff to like you. Well, healthcare staff are going to like you if you de-escalate patients and you don’t escalate patients. Nobody wants a patient that has been escalated by the doctor. So it’s like, “Hey, I’m going to make the patient very angry, and then I’m going to hand the patient off to the nurse who’s going to need to manage them for the next 12 hours.”

 

That’s not very nice. So nurses and other healthcare staff, they love a doctor who can de-escalate. It improves the safety of not only the patients but also the staff. It preserves the therapeutic relationship between you and your patient. I mean, if anybody is angry with you, that doesn’t necessarily mean you have a bad relationship with them, but the relationship right now in the moment is being threatened because the person is angry with you. So that’s also important. You want to be able to complete your assessment, and there are times where you just can’t complete the assessment and there’s nothing you can do about it. The patient is just too psychotic to even talk to you, maybe. I mean, there are lots of other reasons why the patient won’t talk to you that we cover in the podcast and future episodes. But when you can complete the assessment, that is obviously the best-case scenario, because you need to have them answer questions and complete the assessment. So if you can de-escalate the patient, then you have a chance of completing the appointment.

 

And we often ask the patient to take medications they don’t want to take. And if the patient is angry with you, they’re not going to take it. So when you de-escalate the patient, you have a chance of them taking the medication, following your instructions. Why is this especially important in telepsychiatry to de-escalate the patient? I think maybe the number one reason is because if they’re angry with you and they’re in control of the video, they can just shut the video off and you won’t know what happened to the patient.

 

You know, you won’t know what they’re going to do after they’ve logged off of the appointment. And so communication is a primary tool. You want to be able to de-escalate the patient using your words because physically you’re not there. You can’t de-escalate physically.

 

Recognizing Early and Severe Signs of Escalation

There are lots of ways that you can de-escalate the patient, but first, you want to be able to recognize the signs that they’re escalating. Early signs are that the patient’s voice gets louder, it gets more irritable, argumentative. They may be speaking more rapidly and talking without allowing you to speak. Maybe they’re interrupting you, maybe they’re less tolerant to the questions you’re asking, and you can kind of feel that they’re getting more hostile. They’re repeatedly focusing on the same thing, like the same thing that they’re complaining about.

 

Like my patient that I talked about earlier who kept talking about Wellbutrin, and I tried changing the subject, but that just made him more angry. And then you start to get yelling, okay, that is where the patient has now escalated to the point at which they might hurl insults at you, threaten to leave. Maybe they’re getting up and they’re having trouble staying seated.

 

They’re becoming increasingly suspicious and paranoid. Like, “Maybe you’re not trying to help me, doctor. Maybe you’re not even a doctor. Why are you here?” You know, those are like pretty serious signs that they’re escalating. And then when you get sort of toward the most extreme version of escalation, they’re going to be threatening you, threatening the staff, making statements that suggest that they’re going to be violent.

 

Maybe they’re throwing things. They’re hitting the screen, the camera. It happened one time where the patient actually clobbered the camera. So obviously I didn’t do a great job on that appointment and didn’t recognize that the patient was getting angry. Sometimes it can be really subtle. Sometimes you don’t know that they’re angry and they’re just sort of brewing under the surface, especially if this is the first time that you’re seeing the patient.

 

You may not know the signs of their anger. Maybe that patient looks really angry, but they’re not going to escalate. Or maybe they don’t look angry at all and they escalate suddenly. So having continuity with your patients is also important because you get to know what makes the patient angry. You can kind of see what their baseline is.

 

And so if you see these signs of the patient changing their tone and becoming more hostile, then you know that the patient may be escalating. And this is now time to use your skills that I’m giving you to de-escalate.

 

Core De-Escalation Strategies

Okay, skill number one: Regulate yourself first. We’re human beings and we can sense each other’s feelings. We have this uncanny ability to sense when a patient is getting angry. But they can also sense when you’re getting angry. So slow your speech, lower your voice, and recognize that you yourself are getting angry. If you don’t have that self-awareness, if you don’t know when you’re getting angry, then you need to start to learn how to recognize that, okay? Because it’s really important that you present a calm and compassionate demeanor to the patient.

 

If you start to feel negative thoughts toward your patient, this may be a time for you to figure out a way to have the appointment another time.

 

Second, don’t argue with the patient. Don’t argue about the facts, okay? We talked about this in one of the episodes about how to deal with paranoid and psychotic patients. You don’t want to challenge them directly on their distorted beliefs, okay?

 

You want to focus on the patient’s experience and how their belief makes them feel. You don’t want to argue with the facts. You want to acknowledge their feelings without endorsing the inaccurate beliefs, without validating or reaffirming their paranoid beliefs. You want to still acknowledge and validate their feelings. So if somebody thinks that you are against them, you don’t want to say something like, “Nobody is against you.”

 

You want to say, “Hey, it sounds like you’re feeling a bit threatened right now. Tell me more about that.” You want to validate without agreeing, okay? So validation does not mean that you agree. You can acknowledge their anger, their fear, their frustration. You could say, “I see that you’re feeling like nobody’s listening to you.” Unless they are very psychotic, they will see that you’re actually listening to them, okay?

 

This is a pro tip: In life, people want to be heard. And if you can show that you’re listening by rephrasing and by just saying, “I’m listening to you, I hear you, that must be very frustrating for you,” say that to anybody who’s angry with you—whether they’re a patient, whether they’re somebody in your family, or a stranger.

 

That is a very helpful way of de-escalating by just listening. “I can see that you’re frustrated. I can see that nobody’s been listening to you. I want to understand—help me understand.”

 

Another tip would be to slow the encounter down. You don’t want to do rapid-fire psychiatric questions, right? When the patient is escalating, you want to keep your questions to a minimum.

 

You want to ask fewer questions and give the patient an opportunity to vent, to tell their story. You want to prioritize their emotional stabilization. And by the way, that doesn’t mean that you can’t get information just because they’re talking, obviously. So much of the mental status examination can be determined while the patient is talking. In fact, when the patient is really angry, you can use that time to pay attention to the mental status examination and document.

 

But you want to be careful, because if you’re documenting while they’re angry and it’s very obvious that you’re not listening and instead you’re documenting, that could be a problem. So it’s helpful to know how to type without looking down at the keyboard.

 

Another tip is you offer the patient choices. People, when they feel powerless and angry, they want to feel empowered. They want to feel like—by the way, does any of this sound like dealing with children? Because a lot of this can be applied to raising children, because children get angry, they lose control of their emotions, and anyone with children knows that they escalate and they get angry, especially when they feel powerless. So sometimes we do the same thing with children.

 

We want to give them a feeling of power, and the way that you can do that is by offering them choices. And the choices can be all choices that you’re comfortable with. And if you give structured choices where whatever they choose is okay, then that allows you to give them power without really giving them complete control over the appointment.

 

So in telepsychiatry, what does that look like? Well, the choices could be: “Would you rather me talk about the purpose of this appointment, or would you like to first tell me about what’s on your mind?” You could give them a choice like that. You could give them a choice like: “Do you want the staff to sort of back out of the room for a moment while we talk, or is it okay for them to be here?”

 

Sometimes they don’t have a choice in that matter, but if they do, it’s helpful to give them a choice. Sometimes it’s helpful to give them a choice of whether they want to continue with the appointment, like: “Do you want to just take a pause here and we can talk in ten minutes or an hour when you’re feeling a little bit better?”

 

Sometimes it’s about treatment: “Would you like to try the medication now, or maybe we give it a week and you think about it?” So there are all kinds of choices that you can give the patient. And it’s helpful. You know what? I’m going to go ahead and go further and say you should give your patient choices anyway, because you want the patient to feel power.

 

You want them to feel empowered, and they don’t have to necessarily be angry for you to give them choices. So pro tip: give your patient choices when you can.

 

The next tip would be: set respectful limits. So validating a patient’s feelings doesn’t mean tolerating threatening or abusive behavior. You need to set boundaries calmly. And how do you do that?

 

How do you set a boundary without further triggering the patient? Well, don’t do what most people do. What do you think most people do? They say, “Calm down.” I mean, has that ever worked in the history of mankind—”Calm down”? Especially if you say it that way, “Calm down.” Nobody responds to that. So instead of saying “Stop yelling” or “Calm down,” you say, “I can see that you’re very angry and I want to understand, but I can’t understand you if you’re yelling at me.”

 

So that is one way to say it. Keep your tone calm. Even if you’re feeling angry, you need to, as I said before, keep your tone calm. Keep your words brief, okay? So the more you explain about how they need to stop yelling, the more they might get angry. In fact, I have a saying: “The more you explain, the more you lose.”

 

So if you’re explaining a lot all the time to everybody, then they’re not going to really want to listen to you. So you want to keep your words brief. You want to focus on what needs to happen. Like instead of saying “You’re being disrespectful,” you want to say, “I want to make sure that we can hear each other.” And instead of saying “Stop that,” you say something like, “Let’s slow this down so we can work through it, because I really want to understand where you’re coming from.”

 

Another important thing to think about when you’re trying to de-escalate the patient is the expression on your face. If you have a smiling face while they’re angry, they’re going to feel like you’re taunting them, that you don’t care, that you’re not connecting with them. So you want to sort of have a calm, neutral expression. You want to maintain eye contact, but you don’t want to sort of intimidate the patient with a furrowed brow or sort of like glaring at them.

 

You want to have soft eye contact, maintain eye contact. You also want to nod appropriately. You don’t want to be continuously nodding because that can be really annoying, but you want to have small, natural nods to communicate that you are listening. And avoid any expression that makes you look angry, like having a furrowed brow or squinting. Smiling at the wrong time can appear mocking, dismissive, condescending.

 

You don’t want to look bored or distracted, because that can upset the patient. And I would wonder why you’re bored if the patient is yelling at you. But anyway, you want to make sure that you have a nice, supportive expression on your face.

 

And maybe there are things in your background that are triggering a patient and making them angry, and so you want to remove that. So in your background, you have to make sure that it’s not cluttered and messy, because that can be kind of hard to see on the other side of the camera. Anything that will make the patient angry, like people walking around, maybe excessive noises like dogs barking can sort of irritate a patient, doorbells, maybe your phone constantly pinging. So pay attention to your background and what that could be doing to make the patient angry.

 

Maybe there are things in the background that scare the patient. Like, for example, if you’re watching on video, you see the Mandalorian helmet in the back—that could scare a patient. So if that’s the case, you want to remove The Mandalorian.

 

Anything in your background that can be something against their beliefs, like religious material, maybe provocative political things. I mean, do I have to tell you guys to not have political banners in your background? Hopefully none of you do, although I wouldn’t be surprised because I’ve seen a lot of things in my career in telepsychiatry.

 

But just make sure that the background is appropriate and is not one of the reasons why your patient is triggered.

 

Main Takeaways

I hope that this episode has given you a lot of tools that you can use. I would say first and foremost is the tool of listening. So I hope that this episode has given you a lot of tools that you can use to de-escalate a patient over telepsychiatry, but I want to just remind you that when a patient is escalating, your job isn’t to win the argument.

 

Your job is to recognize that the patient is escalating, lower the temperature, preserve the relationship, create a feeling of safety for treatment to continue so that you can finish your appointment. You want to stay calm, listen, validate, set appropriate boundaries, and remember that your voice, your face, and your demeanor can be really powerful in terms of escalating or de-escalating a patient.

 

So the screen can sometimes create physical distance, but it doesn’t have to create emotional distance. And you want to be able to connect to your patient, and they need to feel like you’re connecting with them. So if the patient feels that you are not connecting with them, they might feel that you don’t care, and that’s going to escalate the situation.

 

And there are times when a patient is just escalating to a point where you can’t stop it, and the appointment just needs to stop. And hopefully, you have resources on the other end of the camera to help you. And if you don’t, you have a plan of action when the patient has escalated beyond the point that you can control the outcome of that appointment.

 

I hope this has been helpful for you. I want to close by asking you to put in a five-star review, because that way I can bring this podcast to more people. It’ll be available. Please make a sacrifice to the algorithm gods and put in a five-star review so that this podcast can have more views and therefore reach more people.

 

Thank you so much. And until next time, keep raising the standard.

 

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